AJPH -- eLetters for Parikh, 97 (7) 1198-1208

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FRAMING HEALTH MATTERS:
Shanti A. Parikh
The Political Economy of Marriage and HIV: The ABC Approach, "Safe" Infidelity, and Managing Moral Risk in Uganda
Am J Public Health 2007; 97: 1198-1208 [Abstract] [Full text] [PDF]

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Electronic letters published:

"Be Faithful" Messages Needed for Men and Women: Allison M Herling (18 September 2007)

"Be Faithful" Messages Needed for Men and Women 18 September 2007

Allison M Herling,
Research Fellow
Harvard Center for Population and Development Studies
Send letter to journal:
Re: "Be Faithful" Messages Needed for Men and Women

allison_herling{at}harvard.edu Allison M Herling

Parikh offers a fascinating analysis of the social meanings of marriage and extramarital affairs in southeastern Uganda.1 Her suggestion that "be faithful" messages may be counterproductive because they force extramarital affairs "underground" is baffling, however. Where is the evidence that secret extramarital affairs are more dangerous than publicly acknowledged affairs, or that women have any more power to negotiate condom use or refuse sex when the affair is known? What data show that Uganda's "be faithful" campaigns have increased stigma, putting people at increased risk for HIV and presenting "obstacles to HIV prevention"? Parikh offers no empirical evidence to back these claims.
As an example, Parikh states that a poster encouraging fidelity "equates infidelity with immorality and depicts married people seduced by potential lovers as weak, immoral, and backward." This seems to be a personal opinion. A more useful perspective might have been the opinion of Ugandans who had received such behavior change messages during the crucial years of the late 1980s and early 1990s, when sexual behavior changed (notably, the number of Ugandans reporting multiple partners declined sharply) and HIV prevalence fell by approximately two-thirds in Uganda.2,3
The case of UTODA (a taxi driver's association) as an endogenous avenue through which to promote marital fidelity was instructive. Such a face-to-face, relational approach is likely more effective than a poster or mass-media message in changing behavior. Yet might such an approach also create social pressure around an ideal behavior (fidelity) and force those who fail to conform to the ideal to hide their infidelity? Perhaps any behavior change approach runs such a risk of stigmatizing or encouraging denial among a small number of those with risky behavior. This does not mean that behavior change approaches are inappropriate or ineffective. While Parikh criticizes Uganda's "be faithful" messages, such messages seem to have been extraordinarily effective and may provide a useful model to other African countries struggling to curb the spread of HIV.
Finally, rather than focusing solely on men's extramarital affairs, Parikh might have balanced the scales with discussion (or at least acknowledgement of) women's extramarital affairs. According to a recent analysis by de Walque of couples-level DHS data from 5 African countries, for between 30 and 40 percent of HIV-infected couples it is the woman who is infected.4 Infidelity is not only a male problem, and should not be presented as such.
1. Parikh A. The Political Economy of Marriage and HIV: The ABC Approach, "Safe" Infidelity, and Managing Moral Risk in Uganda. Am J Public Health 2007; 97: 1198-1208.
2. Stoneburner RL, Low-Beer D. Population-level HIV declines and behavioral risk avoidance in Uganda. Science 2004; 304(5671): 714-8.
3. Green EC, Halperin DT, Nantulya V, Hogle J. Uganda's HIV prevention success: the role of sexual behavior change and the national response. AIDS Behav 2006; 10(4): 335-46.
4. de Walque D. Sero-Discordant Couples in Five African Countries: Implications for Prevention Strategies. Population & Development Review 2007; 33(3): 501-523.